National Academies Press: OpenBook

Transit Agency Participation in Medicaid Transportation Programs (2006)

Chapter: Chapter Five - Conclusions

« Previous: Chapter Four - Case Studies of Medicaid and Public Transit Coordination
Page 31
Suggested Citation:"Chapter Five - Conclusions." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Page 31
Page 32
Suggested Citation:"Chapter Five - Conclusions." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Page 32

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31 There were a number of coordination factors evident throughout the synthesis. These factors can foster or impede coordination, and some can dictate the level of coordination. For example, certain capitated brokerages will encourage competition among providers that is the opposite of coordi- nation. It was also determined that rural areas are well ahead of their urban counterparts in coordinating public transit with Non-Emergency Medical Transportation (NEMT). The following are the elements of success—key factors that can foster or inhibit coordination as expressed through the literature review; surveys of transit agencies, state depart- ments of transportation and Medicaid agencies; and the case studies. Not all agencies encountered all of these elements; however, each of the issues listed occurred multiple times and were credited with influencing coordination. These fac- tors are listed based on their affect on coordination: success factors, helpful factors, and challenges to coordination are discussed here. SUCCESS FACTORS These are the factors that must be present for coordination to succeed. By themselves however, these factors do not guar- antee success. • Operational coordination is local—Coordination of NEMT and public transit is fostered and implemented at the local level whether encouraged or inhibited by state and federal government. In the long history of coordination, most of the successes were a result of local level collaboration based on needs and sound business decisions. In the states reviewed as part of this synthesis, many local operators coordinated, whereas the state agencies were not involved. • Building trust—In a number of cases, the trust level becomes very important at the local level. The trust between entities and their management will, in part, determine the level of coordination. Some of the transit agencies reported that they built this trust over many years. • Service delivery model—The service model will, to a significant extent, dictate the potential levels of coordi- nation. Some models clearly foster coordination, some give coordination a lower priority, and others are indif- ferent. The Oregon and Vermont models are examples of successful coordination, whereas other models do not encourage or discourage coordination. • Urban and rural areas—It was determined that rural tran- sit is far ahead of its urban counterpart in the area of coor- dination in general and for Medicaid transportation as well. This was originally accomplished out of necessity; however, it has become an integral part of most rural transit agencies in the nation. • Use of fixed-route service—The appropriate use of fixed-route service is cost-effective and fosters mobility for the clients served. It is true coordination where all parties benefit. Where possible, bus passes should be used. According to the literature and operator responses, the distribution of bus passes is often administratively more effective than distributing tickets two at a time. • Make business sense—Coordination implies and requires mutual benefits; that is, each entity must find the arrange- ment acceptable from a business perspective. The alter- native is for a transit agency to subsidize NEMT. HELPFUL FACTORS If in place, these elements can help foster coordination; how- ever, without them coordination may still be possible, but more difficult. • Understanding of transit concerns—Although NEMT is typically the largest source of transportation funding in rural areas, its managers often have no experience or knowledge of transportation subjects. This lack of understanding has been cited as a major barrier to coor- dination by transit managers. NEMT managers cite concerns similar to those of transit managers when it comes to NEMT services. • State legislation/mandates—To date, legislative efforts have had mixed results across the country based on the information collected for this study, as well as a report by the National Conference of State Legislatures. • Level playing field—A number of transit operators cited the difficulty of competing when the Medicaid service standards are low. Driver training requirements, mini- mum standards, vehicle standards, safety standards, and other requirements typically adhered to by transit are not always required by Medicaid agencies. This encourages two different levels of service—one for public transit and a lower standard for Medicaid clients. CHAPTER FIVE CONCLUSIONS

32 • State level coordination—Coordination of services occurs at the local level, whether the state agencies have coordinated or not. This is seen in states where there is an indifference to coordination at the state level and even where the state is resistant to coordination. Unfor- tunately, coordination is far less likely when the state agencies are not cooperating. CHALLENGES There are some activities and policies that are clear impedi- ments or barriers to coordination. Where these are in place, coordination is more difficult. • Cost transferring—One large broker reported that it was its intention (in a state not reviewed in this synthe- sis) to transfer as many clients to American with Dis- abilities Act (ADA) paratransit as possible; shifting the financial burden from the broker to public transporta- tion and local taxpayers. This is the direct opposite of coordination and will only result in distrust. • Jurisdictional—Medicaid trips by nature often require long distance transportation for specialty medical needs, crossing transit jurisdictional lines. Some opera- tors have cited (local level) problems with the crossing of jurisdictional lines. • Freedom of choice—The Medicaid Freedom of Choice requirement treats transportation as it would a medical program, allowing customers to use any provider they choose. Furthermore, this approach makes coordination problematic by encouraging more small providers. SUGGESTIONS FOR FURTHER RESEARCH Based on the surveys, literature review, case studies, and first-hand observation, coordination can happen in most set- tings. It is evident that further research to facilitate actual NEMT coordination at the transit agency level is necessary in a number of areas. The following issues can be viewed as starting points for in-depth research: • Identification of uniform service standards—One of the primary observations of this study is the difficulty in coordinating when service standards are different between NEMT and public transit. Research could identify NEMT and public transit safety and quality standards and activities that can “level the playing field.” Areas for research include reviewing NEMT and public transit safety (e.g., accidents, incidents, and training) and quality (e.g., on-time, missed trips, vehi- cle breakdowns, and driver experience). • Cost transferring—Cost transferring typically occurs when an NEMT program decides to shift its paratransit riders to the general public ADA service; shifting the burden of funding NEMT from the state Medicaid agency to the local transit agency. Research could iden- tify how widespread this practice is, who benefits, and who pays for this approach. The research could identify a policy to address this issue as well. • Use of fixed-route service—Fixed-route service is clearly beneficial for clients, NEMT, and public transit. Research might help identify where this practice is used and how other states could increase their use of fixed-route service. It would also be helpful to NEMT program managers in understanding how customers can be identified as being able to use fixed-route service (something ADA agencies have been perfecting over the past 15 years). • Tools and strategies for local level coordination—More national research is needed on how to coordinate at the local level. How do successful managers of coordinated agencies build trust, operate service, and manage mul- tiple funding sources? • Education for leaders/policy makers—NEMT and pub- lic transit are very specialized programs. Frequently, the managers of these programs are not well versed in the issues and needs of the other program. A national forum could be developed to identify the concerns, pro- vide the necessary dialogue, and educate leaders of both communities. Local elected officials should also be involved in this effort. • Efforts geared toward communication and trust—The importance of local level coordination cannot be over- stated. Research can help identify how trust can be built and maintained. • Freedom of choice—The freedom of choice requirement for transit is not equivalent to the choice of medical pro- fessionals. Research should look into the effectiveness of this requirement for transit—an industry that is not as closely regulated as for example the medical profession.

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TRB's Transit Cooperative Research Program (TCRP) Synthesis 65: Transit Agency Participation in Medicaid Transportation Programs explores the tasks that may help develop successful public transit-non-emergency medical transportation (NEMT) partnerships. The report examines real and perceived barriers to NEMT and public transit coordination and includes case studies of Medicaid transportation program participation by transit agencies.

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